Similar presentations

2 The patient 10 year old girlAdmitted with acute onset vomiting for 1 day. Started as food, then became yellow/greenAbdominal painWeakness, lethargyPrecipitated by “ asthma attack” – used asthma inhalerPrevious similar episodesNo diarrhoea or constipation

3 Past medical history Recurrent episodes of vomiting – since infancyDiagnosed with gastro-oesophageal reflux disease as infantEpisodes of vomiting more frequent, severe in past 2 years (occur every 1-3 months)Almost always preceded/ precipitated by “asthma attack”. Sometimes even by laughing a lotFrequently resulting in hospital admission – not for bronchospasm but for dehydration and intractable vomiting

4 Been extensively investigated (Cape Town) – barium meal, Xrays, gastroscopy, ?others => all negativeApparently given medication in hospital each time admitted, but not on chronic medication other than steroid inhaler and bronchodilatorParents have not been given a diagnosis as yet – very distressedPast surgical historyNil

5 Birth history Social Family History Term, nil of significanceRecently moved from Cape Town (in past month)Grade 4 at school, doing well, apparently happy8 year old brother, wellStable, caring family environmentFamily HistoryFather has asthma (mild)No known history of migraine in family

8 Management Admitted to ward Rehydrated with IV fluidsAllowed to take orally as desiredPanado, Cyclizine for vomiting

9 Progress Still vomiting in ward for about 2 daysTemperature settled in wardDid not require nebuliser for bronchospasmVery quiet, withdrawn and miserable for 2 daysBy third day, was walking around looking better and vomiting had settled

10 Vomiting in ChildrenVomiting is a symptom, presenting complaint in multitude of disordersRange from gastrointestinal pathology to disease in distant organ (otitis media or intracranial lesion)In children, especially infants, must distinguish from regurgitation – effortless expulsion of gastric contentsIntegrated response to noxious stimuli, coordinated by central nervous system

17 Management Depends on specific causeWhile investigating/ treating underlying pathology – replace lost fluids, maintain hydrationIf mild and child able to drink, can try oral rehydration. Intravenous may also be requiredPharmacologic agents not usually recommendedMay mask signs of serious diseaseUndesirable side-effects in children

23 Cyclic Vomiting Syndrome (CVS)Paroxysmal, especially severe, recurrent vomiting disorderMysterious disorder, unknown aetiology, and pathophysiologySubstantial increase in interest and understanding of disease in past decadePreviously considered rare, may be 2nd only to GORD as cause of recurrent vomiting in children

25 Age and Sex distributionFemales>malesSimilar to distribution in migraine sufferersAll races, nut more in CaucasiansUsually affects children of 4-7 yrs but some as young as 6 mthsBimodal peaks: 4.8 and 35 yrs!

26 Course Often delays in diagnosis Median age of resolution 10 yearsAverage 2.7 years = ±20 episodes in childrenMedian age of resolution 10 yearsIn those whose vomiting resolves, about 1/3 develop migraine headaches around same timeChildren ill <10% of time, but causes substantial medical and academic morbidityRecurrent school absencesRecurrent admissions for IV fluidsRecurrent outpatient visits, hospital stays, missed work for parents

30 Clinical Features Short prodromal phase Episode itself Recovery phase1.5 hoursNonspecific premonitory signs such as pallor, lethargy, anorexia, nauseaEpisode itselfDefined by median of 15 emeses, duration of 24 hoursRecovery phaseFrom last emesis to point of tolerating liquids and food, resume play – remarkably short 6 hours, often marked by sleep. “Turning off a switch”

33 Features (cont) PeriodicityOver 24 period – most common onset between 2am-4am and 6am-8am?relationship to Corticotropin Releasing FactorOver 1-3 month period – commonly every 4 weeks, but only half can predict next episode within 1 week on either side. Rest are sporadicSeasonal – many worse in winter

40 Relationship to migraineCVS thought to be migraine variantOften family history of migraineHigh rate of improvement on anti-migraine therapyCan progress to migraine headaches once CVS episodes have ceased